Estudio de la morbi-mortalidad de la cirugía cardiaca de revascularización coronaria: Efectos clínicos y repercusiones de la circulación extracorpórea.

INTRODUCCIÓN La enfermedad coronaria isquémica representa una de las patologías con más morbi-mortalidad. Hasta la fecha actual el tratamiento quirúrgico, con injertos arteriales, de las estenosis coronarias presenta la mejor tasa de supervivencia a largo plazo. La cirugía cardiaca sufrió un desarrollo espectacular con la aparición de la circulación extracorpórea (CEC) como soporte circulatorio durante los procedimientos en quirófano. Este soporte circulatorio y respiratorio artificial ha permitido hacer frente a todo tipo de tratamientos quirúrgicos (cardiaco, vascular y torácico principalmente), así como de patologías médicas con dispositivos como la ECMO (extracorporeal membrane oxigenation). Sin embargo estos dispositivos de soporte generan en sí mismos una morbilidad no siempre bien valorada. Los efectos deletéreos, no secundarios a accidentes en su manipulación, se centran en un síndrome inflamatorio con repercusión sistémica y que se sobreponen a la inflamación generada por la propia cirugía. En la mayor parte de pacientes el uso de la CEC es imprescindible y sin alternativa, y el estudio de los efectos de la CEC no ha podido realizarse, con una metodología aceptable, hasta la aparición de la cirugía coronaria sin el uso de la CEC (OPCABG). Esta cirugía nos permite comparar grupos de pacientes similares y delimitar el verdadero efecto de la CEC. MATERIAL Y MÉTODOS Se realizó un estudio de cohortes prospectivo, desde el año 2004 al 2007, donde se analizó las repercusiones de estar sometido a la circulación extracorpórea, siendo definido como el factor de riesgo a estudio. Los grupos de pacientes comparados deberían ser similares en características y factores de riesgo. Se analizaron según habían estado sometidos al factor de riesgo (CEC vs OPCABG), según el tiempo al que habían sido sometidos al factor de riesgo (CEC>120 minutos) y su nivel de riesgo quirúrgico según el euroscore (bajo riesgo 7). Se recogieron los datos demográficos, quirúrgicos y de evolución durante su estancia en UCI, con un seguimiento de mortalidad a los 28 días. Como variables secundarias se recogieron: a) la afectación cardiaca (daño cardiaco e infarto perioperatorio), b) revascularización completa, c) afectación respiratoria (protocolo fast-track, VM prolongada), d) afectación renal (disfunción renal, daño renal y necesidad de hemodiálisis), e) alteraciones en la coagulación y requerimientos trasfusiones (hematíes, plasma y plaquetas), f) afectación neurológica (daño neurológico tipo I) y g) consumo y recursos necesarios. RESULTADOS Una muestra final de 322 pacientes fueron estudiados, siendo 237 pacientes sometidos al factor de riesgo estudiado (CEC) y 88 pacientes sin factor de riesgo como control. Ambos grupos presentaron características similares y sin diferencias estadísticas para poder comparar el efecto del factor de riesgo. La mortalidad de los pacientes de riesgo bajo fue de 0% en ambas técnicas; los pacientes de riesgo moderado la mortalidad fue de un 0% (no CEC) vs 1.85% (CEC); y en los pacientes de riesgo alto fue de un 9.1% (no CEC) vs 8.9% (CEC), sin diferencias entre los grupos. Se logró una revascularización completa en un 60% de los pacientes sin CEC y en un 70.9% de los pacientes con CEC sin diferencias entre grupos (p=0.035). La incidencia de IAM diferenciada, fue un de 2.35% en los pacientes sin CEC, frente a un 5.48% en los pacientes con CEC sin diferencias estadísticamente significativas. Se pudo aplicar un protocolo de extubación rápida (fastrack) en un 65.9% de los pacientes sin CEC y en un 42.7% de los pacientes con CEC (51.7% de CEC a 120 minutos), con diferencias estadísticamente significativa (p a 120 minutos), sin diferencias estadísticamente significativas entre grupos, ni en el tiempo de CEC empleado. La incidencia de daño neurológico tipo I se dio en el 1.17% de los pacientes sin CEC y en el 2.81% de los pacientes con CEC, con una relación estadísticamente significativa (p<0.05). Se trasfundió un 31.76% de los pacientes sin CEC y un 71.72% de los pacientes con CEC, con diferencias estadísticamente significativas (p<0.001). Estos resultados han supuesto un riesgo relativo asociado a la CEC de 2.96 veces más en el daño cardiaco de 2.96, de 2.4 veces más en el infarto perioperatorio, de 2.07 veces más en el daño renal, de 2.55 veces más de daño neurológico tipo I, de 5.45 veces más en la trasfusión de hematíes (9.55 veces más de politrasfusión), de 10.02 veces más de trasfusión de plaquetas, de 3.7 veces más de la trasfusión de plasma y de 1.26 veces más en el riesgo de muerte, siendo especialmente significativos este aumento del riesgo en el grupo de pacientes de alto riesgo. CONCLUSIONES La cirugía sin CEC resulta tan segura y eficaz como la cirugía con CEC, consiguiendo tasas equiparables de revascularización completa, por lo que, dada su menor morbi-mortalidad asociada debería ser de preferida elección ante los casos debidamente seleccionados. La utilización de CEC aumenta de manera estadísticamente significativa la aparición de complicaciones respiratorias, renales y neurológicas en pacientes con un riesgo quirúrgico preoperatorio alto. En pacientes con riesgo quirúrgico preoperatorio bajo o moderado el efecto de la CEC en el índice de complicaciones no es estadísticamente significativo. El tiempo de exposición a la CEC es un factor clave en la aparición de complicaciones, como son la necesidad de trasfusiones (hematíes, plasma y plaquetas) y con una estancia prolongada en UCI, pudiendo fijar en 120 minutos el límite recomendable de exposición a la misma. El uso de la CEC conlleva un aumento de la mortalidad no estadísticamente significativo en todos los grupos de riesgo. Si la duración de la CEC supera los 120 minutos y se aplica a pacientes de alto riesgo la mortalidad aumenta más del doble, siendo este aumento estadísticamente significativo. La CEC consume más recursos económicos que la cirugía sin CEC, pero son las complicaciones quirúrgicas las que realmente encarecen los tratamientos al perpetuar la estancia en UCI, la ventilación mecánica, la necesidad de trasfusiones, etc., por lo que es de crucial importancia adecuar la técnica quirúrgica a cada paciente para minimizar el riesgo de aparición de complicaciones

Role of Crystalloids in the Perioperative Setting: From Basics to Clinical Applications and Enhanced Recovery Protocols

Perioperative fluid management, a critical aspect of major surgeries, is characterized by pronounced stress responses, altered capillary permeability, and significant fluid shifts. Recognized as a cornerstone of enhanced recovery protocols, effective perioperative fluid management is crucial for optimizing patient recovery and preventing postoperative complications, especially in high-risk patients. The scientific literature has extensively investigated various fluid infusion regimens, but recent publications indicate that not only the volume but also the type of fluid infused significantly influences surgical outcomes. Adequate fluid therapy prescription requires a thorough understanding of the physiological and biochemical principles that govern the body’s internal environment and the potential perioperative alterations that may arise. Recently published clinical trials have questioned the safety of synthetic colloids, widely used in the surgical field. A new clinical scenario has arisen in which crystalloids could play a pivotal role in perioperative fluid therapy. This review aims to offer evidence-based clinical principles for prescribing fluid therapy tailored to the patient’s physiology during the perioperative period. The approach combines these principles with current recommendations for enhanced recovery programs for surgical patients, grounded in physiological and biochemical principles

Echocardiography phenotypes of right ventricular involvement in COVID-19 ARDS patients and ICU mortality. post-hoc (exploratory) analysis of repeated data from the ECHO-COVID study

PurposeExploratory study to evaluate the association of different phenotypes of right ventricular (RV) involvement and mortality in the intensive care unit (ICU) in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19).MethodsPost-hoc analysis of longitudinal data from the multicenter ECHO-COVID observational study in ICU patients who underwent at least two echocardiography examinations. Echocardiography phenotypes were acute cor pulmonale (ACP, RV cavity dilatation with paradoxical septal motion), RV failure (RVF, RV cavity dilatation and systemic venous congestion), and RV dysfunction (tricuspid annular plane systolic excursion &amp; LE; 16 mm). Accelerated failure time model and multistate model were used for analysis.ResultsOf 281 patients who underwent 948 echocardiography studies during ICU stay, 189 (67%) were found to have at least 1 type of RV involvements during one or several examinations: ACP (105/281, 37.4%), RVF (140/256, 54.7%) and/or RV dysfunction (74/255, 29%). Patients with all examinations displaying ACP had survival time shortened by 0.479 [0.284-0.803] times when compared to patients with all examinations depicting no ACP (P = 0.005). RVF showed a trend towards shortened survival time by a factor of 0.642 [0.405-1.018] (P = 0.059), whereas the impact of RV dysfunction on survival time was inconclusive (P = 0.451). Multistate analysis showed that patients might transit in and out of RV involvement, and those who exhibited ACP in their last critical care echocardiography (CCE) examination had the highest risk of mortality (hazard ratio (HR) 3.25 [2.38-4.45], P &lt; 0.001).ConclusionRV involvement is prevalent in patients ventilated for COVID-19 ARDS. Different phenotypes of RV involvement might lead to different ICU mortality, with ACP having the worst outcome

Systematic review and literature appraisal on methodology of conducting and reporting critical-care echocardiography studies: a report from the European Society of Intensive Care Medicine PRICES expert panel

International audienceBackground: The echocardiography working group of the European Society of Intensive Care Medicine recognized the need to provide structured guidance for future CCE research methodology and reporting based on a systematic appraisal of the current literature. Here is reported this systematic appraisal. Methods: We conducted a systematic review, registered on the Prospero database. A total of 43 items of common interest to all echocardiography studies were initially listed by the experts, and other “topic-specific” items were separated into five main categories of interest (left ventricular systolic function, LVSF n = 15, right ventricular function, RVF n = 18, left ventricular diastolic function, LVDF n = 15, fluid management, FM n = 7, and advanced echocardiography techniques, AET n = 17). We evaluated the percentage of items reported per study and the fraction of studies reporting a single item. Results: From January 2000 till December 2017 a total of 209 articles were included after systematic search and screening, 97 for LVSF, 48 for RVF, 51 for LVDF, 36 for FM and 24 for AET. Shock and ARDS were relatively common among LVSF articles (both around 15%) while ARDS comprised 25% of RVF articles. Transthoracic echocardiography was the main echocardiography mode, in 87% of the articles for AET topic, followed by 81% for FM, 78% for LVDF, 70% for LVSF and 63% for RVF. The percentage of items per study as well as the fraction of study reporting an item was low or very low, except for FM. As an illustration, the left ventricular size was only reported by 56% of studies in the LVSF topic, and half studies assessing RVF reported data on pulmonary artery systolic pressure. Conclusion: This analysis confirmed sub-optimal reporting of several items listed by an expert panel. The analysis will help the experts in the development of guidelines for CCE study design and reporting

The PRICES statement: an ESICM expert consensus on methodology for conducting and reporting critical care echocardiography research studies

International audiencePurpose: Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies. Methods: The PRICE panel identified lists of clinical and echocardiographic parameters (the “items”) deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts’ opinion into account. Results: A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed. Conclusion: The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results

Echocardiography phenotypes of right ventricular involvement in COVID-19 ARDS patients and ICU mortality: post-hoc (exploratory) analysis of repeated data from the ECHO-COVID study

International audiencePurpose: Exploratory study to evaluate the association of different phenotypes of right ventricular (RV) involvement and mortality in the intensive care unit (ICU) in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). Methods: Post-hoc analysis of longitudinal data from the multicenter ECHO-COVID observational study in ICU patients who underwent at least two echocardiography examinations. Echocardiography phenotypes were acute cor pulmonale (ACP, RV cavity dilatation with paradoxical septal motion), RV failure (RVF, RV cavity dilatation and systemic venous congestion), and RV dysfunction (tricuspid annular plane systolic excursion ≤ 16 mm). Accelerated failure time model and multistate model were used for analysis. Results: Of 281 patients who underwent 948 echocardiography studies during ICU stay, 189 (67%) were found to have at least 1 type of RV involvements during one or several examinations: ACP (105/281, 37.4%), RVF (140/256, 54.7%) and/or RV dysfunction (74/255, 29%). Patients with all examinations displaying ACP had survival time shortened by 0.479 [0.284–0.803] times when compared to patients with all examinations depicting no ACP (P = 0.005). RVF showed a trend towards shortened survival time by a factor of 0.642 [0.405–1.018] (P = 0.059), whereas the impact of RV dysfunction on survival time was inconclusive (P = 0.451). Multistate analysis showed that patients might transit in and out of RV involvement, and those who exhibited ACP in their last critical care echocardiography (CCE) examination had the highest risk of mortality (hazard ratio (HR) 3.25 [2.38–4.45], P < 0.001). Conclusion: RV involvement is prevalent in patients ventilated for COVID-19 ARDS. Different phenotypes of RV involvement might lead to different ICU mortality, with ACP having the worst outcome